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11/26/2003 10:27 FAX 925 943 2366 GEOSYNTEC-1M1'C Z002 <br /> Nov 25 03 05: 44p CJ <br /> of StocktanPW-Permit (1937-8901 10. 1 <br /> 68240 <br /> CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> aAppplicant's NRmp �G o Date 10// 3 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> Subject to the General Provisions and Special Conditions,and ail <br /> i°W v �Sbo Phone °I� `/ -°143-30 <br /> Addross work must conform to thero ecYs approved Storm Water Pollution <br /> P I PP on <br /> City WcJti1 u�- C-ra-+ k State f� Zip Prevention Plan or the City of Stockton Storm Water Pollution <br /> / Prevention Maintenance Staff Guide,whichever is applicable, <br /> Location of Proposed Work,etc. <br /> Owner! ontractor Address 1971 r o'1a By <br /> Estimating Starting bate Completion Date �0 F c/ 3_ Permit Expiration Date 12^]'<—o 3 <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> SG-rh F w SFut"L, r o f <br /> Ga to,c-4e'o5 "Jc� tti timid/-� �Oenfeti� <br /> The above named applicant hereby requests pamussica to- <br /> PERMIT FEE............................$ <br /> Additional Footage Fee- $ <br /> Trench Fee......---..................... $ <br /> f� p Sewer Tap Deposit....................$ <br /> c4e) ✓f'�C-P TOTAL DEPOSIT.........$ <br /> Building Permit No, <br /> Improvement Pian No. <br /> Supplemental Conditions: <br /> An y /�QGjv C�# G/� *% ,a don r9 Cc�v� 5. <br /> /`}�( vS/4"�rk�;.7 S f Grk!l �e /'�tv►.t� /"t'�'' <br /> Show sketch above cr reler to crewing subrnmed y-Q <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit,as wail as all applicable City ordinances,resolutions, <br /> Standards and Specifications currently in effect,and to pay to the City its actual cost for removal and proper replacement of any item which does <br /> not meet the above requirements,Failure to comply will be cause for revocation of permit.Applicant agrees to indemnify and hold the City <br /> harmless against any and all losses,costs,or damages resulting from injury to persons,death of person or damage to property occurring at the site <br /> of,or as a result of,work to be performed under this permit.A certificate of insurance shall be submitted to the City Risk Manager prior to issuance <br /> of this permit. <br /> PERMITTEE SHALLL(209)937-6366 A CONTROL NUMBER NO LESS THAN 24 HOURS, BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE STA T OF WOR RIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT.IF WORK DOE 13EGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937.8411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed: J<� C[YU4[� Phone: <br /> 1st-Permittee(white) 2nd-Inspection(pink) 3rd-File(yellow) 4111-Finance(white) <br />